There is
no very precise way of defining the concept of nursing shortage, but an
explanation of this concept can give a clear understanding of the problem.
Health care organizations in USA are experiencing increased demand for nurses
while the supply is very low. Health care organizations encounter nursing
shortages when their demand for nurses to fill job openings in the organization
is higher than the available supply of qualified nurses. Usually such vacancies
remain unfilled for a prolonged period of time and thus causing shortage. Both
the demand and supply factors cause the apparent shortage. For instance
experienced nurses in key specialties such as intensive care, midwifery and
others are in short supply and the demand for these skills is so high in most
health care organizations.

In USA
today, 56% of hospitals report that they are using agency or travelling
nurses-at expenses because they can not fill vacancies (American Hospital
Association 2001). On average, nurses work an extra 8weeks and a half of over
time per year as a result of nursing shortage (Service Employers Interest Union
2003). It is also estimated that by the year 2020 there will be at least
400,000 fewer nurses available to provide care than will be needed. The
American Association of Colleges of Nursing reports that there are roughly
21,000 fewer nursing students today than in the year 1995. Despite the shortage
now, indications are that the demand for health care and public health in
general will continue to grow through this first decade of the millenium. This
is attributed to demographic transitions (a growing population with a greater
number of elderly people), advances in medical practice and technology, the
impact of new diseases and infections [e.g. Human Immunodeficeincy virus (HIV)
Acquired immune deficiency syndrome (AIDS)], and changes in public (consumer)
expectations of the public health system.

Health
care being a 24 hour, 365 day industry, its resources have to be deployed to
match continuous, but changing demands. The most important resource in this
labor intensive industry is its personnel: they account for up to two thirds of
total expenditure, and even then remuneration is often inadequate because of
budget limitations. The health care industry is so unique in that the
manufacture of the commodity that is purchased and the consumption of that
commodity take place at the same time [6]. The interaction between
patients/consumers and nurses is an integral part of the provision of health
services. This intensive use of labor for service delivery, and the possibility
of variability in professional practice, requires that the attention of public
health managers be directed towards managing the performance of critical
services such as nursing services. Trends in worker force for public health are
even much important now than ever before because of the pressure and efforts
towards managed care and cost reduction. The already complicated puzzle of
nursing shortage in a managed care health care system is further complicated by
the requirements of quality assurance.The requirements of quality assurance have shifted the discussion
further, from the focus of quality control designed to reduce errors in
existing patterns of care, to continuous quality improvement designed to
achieve higher levels of, and increased uniformity in standards of care and
performance. These changes in the health care system require even more well
qualified nurses and health professionals in general. Therefore individuals who
are already involved in public health management or studying to develop careers
that may require public health management skills, should be well versed with the
ever shifting trends in the public health work force.

To
develop a good analysis of this important concept of trends in public health
work force, it is necessary to break down the different health disciplines into
manageable categories for separate analysis. However, it is again also not
feasible to analyze such trends in each discipline with precision in one
chapter. Therefore for this chapter to sustain a reasonable analysis and
commentary it will focus on the Nursing discipline and later inclusion of the
other disciplines will be considered.

TRENDS IN THE NURSING WORK
FORCE

Many
professions are involved in the provision of public health or health care in
general, but the largest cohort is made up of nursing personnel. In most of the
health care systems in most countries, Nurses form the majority of the health
care providers and the backbone of health care systems. They are the frontline
implementers of the important basic health care and public health
interventions. The changing scope of Nursing practice (i.e. from Licensed
Practical Nurses through Registered Nurses to Nurse Practitioners), lack of
equitable access to health care, emergence of new disease patterns and managed
care have all synchronously enhanced the importance of Nursing to public health.
The trends in Nursing work force that have resulted therefore pose a formidable
challenge to public health today and in the future.

A recent
survey examining the status of nursing and midwifery identified that many
developed and developing countries are experiencing serious shortages in
adequately prepared individuals to meet the nursing needs of their populations
[9]. In a case study of Nursing health human resources in Canada (O’Brien-palls
e tal 2000), also highlighted that the key concerns related to the current
trends in Nursing work force are; inadequate numbers of trained personnel to
meet health system needs, limited opportunities for improved nursing and
midwifery in relation to primary health care, lack of legislation to guide
nursing resource development, limited influence of nursing on health policy,
unacceptable working conditions and poor career opportunities.

The problem of Nursing shortage in the USA is
not happening for the first time. During and after the Second World War,
hospitals struggled with a nursing shortage [1]. For nurses returning from the
military, job in industry or in doctors offices, advanced education under the
G.I bill (Government Issues) or marriage were all more attractive than the low
paying, long hours of hospital nursing. In 1950, the American Hospital
Association reported 22,486 vacancies for graduate nurses.As of March 2000, the total number of
licensed RNs in the USA was estimated to be 2,696,540, an increase of 137,666
over the 2,558,874 licensed RNs reported in 1996 [20]. Although this was a 5.4
percent increase in the total RN population, it was the lowest increase
reported in the previous national surveys. By comparison, the highest increase
in the RN population was experienced between 1992 and 1996 when the total
number of RNs increased by an estimated 14.2 percent or 319,058 (from 2,239,819
to 2,558,874). Today in USA the American Hospital Association (2002) has
recently estimated 126,000 vacancies or a rate of 11%, as the unified position
of the current nursing shortage. This is expected to worsen if concerted
strategies are not employed to improve the situation. The shortage is
widespread and articles are appearing in local, national and international
media about the impact of nursing shortage on public health. However the
question to ask in this chapter is, How does a public health manager know with
certainty that there is a shortage of nurses in the labor market?

INDICATORS OF NURSING
SHORTAGE

There are
four main process indicators that can be used to follow and highlight trends
and variations in nurse staffing shortages or over supply [2]. These are;

·Vacancy Rates;

The state
of California only has nurse vacancy rates that hover around 20% [19].According to the American Hospital
Association (June 2001), 126,000 nurses are currently needed to fill vacancies
in USA hospitals and it further quotes that 75% of all hospital personnel
vacancies are for nurses.The most
common proxy measure of vacancy rates, at both the state and national level, is
the index of newspapers help/ vacancy adverts produced by the conference board,
or other bodies of professional nursing organization. Vacancy rates generally
represent the extent to which an organization is unable to recruit staff to
fill vacant posts and this is often used as an indicator of shortages. Trend
information of vacancies is helpful in monitoring the impact of shortages or
other imbalances between supply and demand. A look in any of the major local
Newspapers and national papers show that nursing Jobs are the most advertised
posts. In fact the shortage may be under estimated if one goes by vacancy rates
because of “suppressed vacancies” [19] i.e. posts not advertised because of no
expectation of successful recruitment, hidden vacancies or posts filled with
less qualified or less skilled individuals.

§Nurse
Staff turnover rates;

This is
based on transfer with in an organization and wastage i.e. controlled wastage
e.g. retirement, redundancy and redeployment, and uncontrolled or voluntary
wastage owing to employ leaving for their own reasons mainly career
progression, better paying new jobs and dissatisfaction in nursing.

§The
Extent of Use of Temporary Staff;

Temporary nursing staff usage such as bank
nurses, agency nurses, travel nurses or internal float pool nurse, is an
indicator of shortage or difficulties in recruiting staff. The use of temporary
staff represents an increased trend towards a casualized work force, and “just
in time” staff replacement [9]. This tendency also is very common in situations
where qualified work force is difficult to find. This approach is vulnerable to
laxity in quality of nursing care.

§The
Number of Overtime/ Excess Hours that are worked;

The
extent to which permanent staff nurses regularly and consistently have to work
additional hours is also an important proxy indicator of shortage.

Other
potential shortage indicators may include; Pre-registration nursing and
midwifery education (gives an indication of trends in the attractiveness of
nursing as a career), the number of acceptable applicants per advertised
vacancy (if low, this is an indicator of a tightening labor market), patients’
mortality rates, adverse events after surgery, increased cross infection,
increased accidents and work related injuries among existing nurses [17].

§Number
of new graduates Registered for nursing practice

The most
direct ways of measuring the nursing shortage is through use of registers from
state licensing boards. For instance, according to the National Council of
state boards of nursing, the number of first-time US-educated Nursing graduates
who sat for the NCLEX-RN- the national licensure examination for all entry
level RN; decreased by 26% from 1995-2001. This is a very objective measurement
that can not be manipulated by employers.

FACTORS CONTRIBUTING TO
NURSING SHORTAGE

One of
the key determinants of the labor market behavior is age. Nursing in USA as in
most first world countries in the North has an aging population. This has a
number of employment policy implications. Older nurses may be more likely to
wish to reduce the number of hours they work, and can have differing needs for
life long learning than young or more recently experienced nurses’ [2]. The
average age of registered nurses has risen from 44.3 to 45.2 years, therefore
leaving only 20 years period to retirement. Many nurses will be ready to retire
and deciding on how to replace these lost skills will represent a growing
challenge for the public health system.

The population of USA is aging i.e. the older
population (65+ years) numbered 35 million people in 2000, an increase of 3.7
million or 12% since 1990.The number
of Americans aged 45-64- the “baby boomers” who will reach 65 over the next two
decades increased by 34% during this decade (A profile of older American
2002).This implies that more health
care and testing are increasingly required for this vulnerable population in
addition to the already existing large population needs. It is therefore
reasonable to conclude that as the graying population increases the shortage of
the nursing work force will also increase or even worsen. This implies that the
problem of baby boomers is going to hit the nursing work force with a double
effect i.e. increased demand on the limited nursing resources by the aging
population and reduction of available skilled nurses for recruitment due to
retirement. USA like all other countries faced with the shortage, will most
likely carry on this trend of nursing shortage in the future as attrition and
retirement rates among nurses continue to parallel out put of trained nurses.
The result will be a cumulative loss of experienced personnel and the impact to
public health will be disastrous.

The most
reliable out put for nursing human resources like any other profession, are the
nursing schools. Fewer students are enrolling in nursing schools. According to
Richard Penell 2002, nursing school enrollment has dropped in each of the last
three years. The in-take of new nursing students today is less by 21,000 than
it was in the year 1995. The number of nursing educators is also declining as
budget cuts have limited funding for nursing education. The few nurses who get
trained and the most talented with postgraduate degrees, have found
opportunities for better pay and more rapid advancement in fields outside
nursing, medicine or public health.

Today
unlike in the past, health professionals and nurses in particular work in a
variety of health’s related settings, not just hospital. These settings may
include health insurance companies, research companies, pharmaceutical
companies and many others. The number of new nurses needed for health care and
related fields is not keeping pace with demand given the new wide array of job
opportunities available today. Most of the new non-traditional settings where
nurses are working provide competitive salaries, good work environment, and
nursing professional autonomy. This trend forces the traditional public health
employers of nurses to compete for the few nurses in an increasingly
competitive market place that demand bigger salaries. The ramification of this
tendency is in part the nursing shortage, high costs of health care, and
subsequently inaccessibility to public health care services.

The
reduction in the pool of available nurses over many years combined with rising
demand for nurses in both acute care and community settings has also
contributed to this catharsis of nursing shortage. The shortage experienced
today represents a build up of smaller shortages that have gone unattended to
over the years. The factors responsible for the reduction in pool can be
summarized under the following category [11].

¨Failure by health systems to improve nurse remuneration as
a strategy of cost containment in managed care systems.This has made the nursing profession
unattractive to new students in colleges and has also discouraged those already
in nursing to early retirement, or complete change of career

¨The pattern of turn over rates by age cohorts and life
events. An example of this is pregnancy, which is a fact of life in a
profession where women account for, nearly 90 percent of the work force.

Why
nurses have to leave the profession and why no new people join nursing? The
answer to this question also provides another important factor that silently
and continuously contributes to the nursing shortage. The answer is more
inclined to conditions of employment and wages. Studies have indicated that
poor career advancement, poor wages, increased work load and poor work place
relations are the most important factors in determining quitting intentions
among nurses [7]. In addition, if you take into account that one of the most
important characteristics of the nursing profession is the large amount of
shift work- for most individuals shift work is more stressful than working
normal hours (Costa C.1996).

Of the
total licensed RN population in March 2000, an estimated 58.5 percent of RNs
reported working full-time, 23.2 percent reported working part-time, and 18.3
percent reported not being employed in Nursing [20]. These findings indicate
that a considerable number (18.3%) of trained nurses are not available for
employment in nursing jobs. It also shows that increasingly a good number of
nurses (23.2%) are available for less time to provide nursing care, this as
indicated by the number of nurses working part time. In a situation of already
raging shortage the country can not afford the luxury of having any number of
nurses working out of the nursing jobs nor being available for less than normal
working time. This shows the intertwined nature of the factors that are
contributing to nursing shortage in USA today.

THE CONSEQUENCES OF NURSING
SHORTAGES

The
effects of the shortage of nurses on public health are significant in terms of
the impact on organizational costs and in relation to quality and continuity of
care provided. Shortage of nurses deprives the health care setting of necessary
tools for advancing quality and cost-effective care [12].

The
current nursing shortage has opened up hospitals to lapses in patient care that
happens when staffing levels are low. The first things to go are less critical
tasks such as bathing patients and changing bandages. As these interactions
fall away nurses spend less time in each room and start to miss subtle changes
in the patient’s condition. At first the icing-on-the cake stuff doesn’t get
done, like baths, and at first nurses may cope well, but then it can get so
busy. Commonly shortage in nursing staffing can lead to increased mistakes, lab
tests mislabeled, medications may come late or patient calls may go unanswered
[18]. Literature has also for long indicated that hospital acquired infections,
bedsores, patient falls, wrong drug dozes and other preventable complications
can increase in a situation of decreased nurse staffing levels.

The
nursing shortage has also consistently come to the forefront of recent health
news. The New England Journal of Medicine (May 2002), published the results of
a study by the Harvard school of Public Health and Vanderbilt University school
of Nursing stating that a direct link exists between the number of registered
nurses and the hours they spend with patients. The researchers, utilizing 1997
data from more than 5 million patient discharges from 799 hospitals in 11
states, found that there were consistent relationship between nurse staffing
variables and five adverse patient outcome. The five adverse out comes are
urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding,
and increased length of hospital stay in medical and major surgery patients
[16]. The same study also showed that higher RN staffing was associated with a
2 percent to 25 percent reduction in adverse outcomes. Clearly this creates a
threat toquality of health care. The
cost associated with patients’ complications can be substantial, and patient
complications arising from nursing shortage propagate a cycle of increased
demand on the already meager nursing resources.

Failure
to address nursing shortage therefore results into failure to reduce the rates
of adverse outcomes or complications, failure to reduce hospital costs as well
as significant financial and psychological costs to patients and their
families. James Buchan and Ian Seccombe (1995) noted that the main issues for
management arising from nurse shortage and absence are;

·Impact on quality of care

·Impact on continuity of care

·Impact on productivity

·Impact on organizational costs

·Effect on remaining staff-overwork

·Time spent organizing cover

·Time spent by remaining staff monitoring temporary staff

·Attendance control policies and practice

·Measuring and monitoring absence and,

·Building in absence rate in staffing levels.

The
options available to managers faced with the above problems that accrue from
nurse shortage, range from doing nothing so that workloads of remaining staff
are increased and hence burning out, through juggling with available staff by
transferring employees,to recruiting
temporary cover staff from an internal bank or external agency.Other options that are used in practice
include re-allocation/ delay/ or postpone work, available staff working long
hours and employment of temporary additional staff or less qualified staff [8].
These options can not help the situation, but only serve to propagate the
problem and may be the cause of other concerns related to quality and standard
of care.

The
problems of nursing shortage need concrete strategies if quality care,
continuity of care and cost containment is to be addressed. The options of
internal reallocation, delay and postponement of work only work to decrease the
quality of care, to erode staff nurses’ morale and curtail continuity of care.

STRATEGIES FOR ADDRESSING
NURSING SHORTAGE

The
current and future workforce shortage has and will continue to affect the
health care system and health of the American public.Timely action to address the problem of nursing shortage will
save the health care system a lot of time and other resources which may be
needed in future to overcome the cyclic problems that may result. Some
organizations i.e. government agencies and health policy makers have started
devising strategies that will increase the supply of registered nurses.

This
section reviews the potential interventions that can be employed and are being
employed to address nurse recruitment and retention difficulties in order to
overcome the shortage. All the strategies highlighted, though explained
independently, in actual practice of public health management an integrated framework
using the different strategies is the best approach to improving nurse
recruitment, retention and utilization.

§New
Technologies to Automate Non-Valued Tasks

Analysis
of registered nurses work still shows that a significant portion involves
non-direct care activities. This figure may go as high as 40% in some cases
(American Academy of Nursing 2002). This situation leads to ineffective use of
nursing resources and could be a significant contributor to the growing
workforce shortage. Therefore automation of non-valued work tasks in order to
make more time devoted to direct patient care is still a potential strategy
that can help in alleviating the shortage. An example of such a strategy that
has shown to be effective is computer based charting of patient’s progress, and
requisition of drugs from the pharmacy on the computer instead of a nurse
walking to the pharmacy.The pneumatic
tube system used now in most hospitals to forward laboratory samples taken from
patients to the central hospital laboratories is another vivid example. These
strategies help by reducing workload, preventing burning out and thus
increasing the number of nurses available for full time work schedules.
Automation has been implemented in some health care settings, but more innovations
can still be implemented. This strategy can also be viewed as a revolution to
redesign public health care delivery by finding new ways of delivering public
health care with fewer health professionals. However the challenges and
problems of applying new and emerging technologies in health systems should not
be under estimated. Initial capital investment, education, training and errors
may increase the costs of health if the strategy is not well thought through
before implementation.

§International
Recruitment

In an era
of globalization with free mobility of labor, no country can anticipate being
totally self-sufficient in its nursing resources.This is more important and relevant to the first world countries
because of their big population and aging section of the population. In
2001/2002, about 4% of the new nurses on the UK nursing register came from
non-UK sources [10]. The strategy of importing ready-made nurses from other
countries is apparently a cheap quick fix for countries facing political pressure
to solve the shortage. Though traditionally international recruitment has taken
place in countries such as Philippines, China and Caribbean, a potential source
exists among developing countries of Africa, which share Official language,
common educational and post-colonial ties with USA. The UK is actively using
countries that are members of the Common Wealth Association as sources of
nursing resources.However, to achieve
better results from the international recruitment strategy there is need for
cooperation at organizational and government level to identify a scope for a
win – win situation. The current agreement between Spain and England for
Spanish nurses to work in the National Health Service in England for a defined
period of time provides a good template [10]. Such cooperation helps to avoid
the political and ethical dilemmas in international recruitment and in
preventing a situation of exporting the problem of nursing shortage to already
burdened developing countries. The introduction of special immigration
legislation to facilitate nurses and other profession access to work permit is
one step taken by the USA government in using this strategy [2].

The
national registered nurses (RN) turn over rate for USA was 18 percent in the
year 2000, representing the highest in decades [19]. Staff vacancies are
indications of staff shortages and are the reflection of the extra work and
strain imposed on the existing staff [11]. Legislation and policies that
require specific hospital wide Nurse-to-patient ratio, just as there are
minimum ratios for airlines, daycare centers and other areas of public safety
are vital in enforcing organizations that choose not to recruit as away of cost
containment. Improvement in this regard can potentially attract re-entry
nurses, part time to full time employment and enrollment in nursing schools.
For instance in California if all the part-time RN increased their employment
to full-time, the overall RN labor supply would increase by approximately 11
percent [11].

The top
most reasons nurses have cited for discontent, early retirement and changing
from nursing to other jobs are, increased work road, inadequate staffing, poor
patient ratios, harmful changes in health care delivery systems as away of cost
containment and decreased quality of care. These factors have a direct effect,
and response is the alarming erosion of care standards and hemorrhaging of
nurses away from the bedside or other public health positions. A comparable
turn around to overcome nursing shortage due to factors such as early
retirement, change of professions and poor work conditions, can be achieved if
strong policies and legislation on nurse-patient ratio and remuneration are adopted
by state and federal efforts without crippling delay.

Staffing
levels and workplace satisfaction affects patient care and nurse retention
rates. Patient care suffers as fewer nurses are left to care for older and
sicker patients. Therefore public health managers need to actively participate
in policy and legislation such as the Nurse Reinvestment Act 2002, which is
going to give scholarships and grants to help hospitals retain the nursing
staffs and encourage individuals to enter the nursing professionals. Similar to
this, following the Second World War the nursing shortage that resulted was in
part eased by the liberal use of licensed practical nurses and the Nurse
training Act of 1964 which funded nursing schools expansion and student loans
[1]. In addition individual hospitals responded to the shortage with various
innovations such as offering on-site childcare to enable nurses with families
to rejoin the work force, and expanding the duties of licensed practical nurse.
Other legislation aimed at improving nurse-patient ratio, remuneration and
workplace environment should also attract the same attention.

To
achieve the goal of increasing the number of nurses available for public health
requires a concerted effort by all stakeholders to spawn initiatives such as
pay increase, family friendly policies, improved working conditions and role
enhancement opportunities. The efforts to achieve the goal of eliminating
nursing shortage should avoid the fragmented approach of policy makers and
instead focus on an integrated approach [11]. The problem of nursing shortage
is a chain of problems that includes issues such as nurse recruitment,
retention, high quality care, managed care, patient satisfaction and more
specifically low pay, poor job prospects, low morale, stress, increased work
load and poor staffing levels. For unless all constituents of the chain are
tackled and the linkages recognized, the chain which is only as strong as its
weakest link will break.

§Establishment
of Bank Nurses to provide service in shortage/Crisis

To
address the problem of nursing shortage and to provide a buffer during
work-shifts experiencing shortage several ways can be used. Staffs may stay on
at the end of their normal shift, taking time off in lieu or receiving payment
for their extra hours, or they may be part of a nursing pool deployed to work
wherever there is a shortfall. This pool is what is referred to as bank nurses.
Permanent staff may also work additional shifts by registering with an in-house
trust bank, also called local organization or hospital nurse bank.

The
buffer of bank nurses is very good option in some specialties e.g. theatre
nursing and intensive care where staff transferred from other care environments
would not have the relevant skills to operate effectively.The use of bank nurses is one of those
strategies that are regarded to affect the quality of care provided as is
overtime working [8]. Therefore use of bank nurse as a cover option is more
effective where there is local control over the nurse bank. This is more likely
to lead to employment of bank nurses who are acquainted with the work and care
environment. Large general banks are less accessible-to by individual
organizations, and organizations have little control over choice of nurse,
quality of the nurse and cost of hiring them.

§Marketing
and Continuos Recruitment

The
health care industry should adapt the latest methods to compete and survive,
such as use of more marketing tools to attract nurses who may be practicing in
other industries and promote diversity [6]. The health care industry and public
health in general has lagged behind other industries in securing high
performance marketing personnel to help them in the marketing strategy for
attracting personnel. The result is that newly qualified young nurses end-up
being employed in the non-traditional organizations that now employ nurses e.g.
pharmaceutical industries, marketing health products and others. However, with
the development of health maintenance organizations, this trend may be changing.

Public
health organizations must have a continuous influx of nurse-candidates for
potential employment.New employee
positions are required as a marketing strategy and as service areas expand or
new-services are initiated. Recruitment should occur even when there is a
limited growth or even decline in service capacity, because individuals with
specialized skills or training who leave the organization must be replaced and
services or technologies that have been revised or modified must be staffed
[6].The strategy of continuous
recruitment of nursing personnel may play an important role in helping the
organization to adapt and remain competitive. Employees who have recently
finished professional nursing training are an important source of information
on new methods and techniques in service delivery that allow the organization
to remain competitive in its traditional services.

§Training
and Development

Investment
in the existing nursing human capital of a health service organization through
a well managed training and development activity pays long term dividends for
public health organizations. Improvement of the skill and abilities of LPNs to
RNs and Nursing Aides to LPNs can contribute to sustained reduction in the
shortage of well trained nursing work force. The changing environment of health
services industry and public health in general, ensures that the training and
development of current nursing staff members contribute to organizational
performance in one part, and attracting other young people to the nursing
profession on the other hand. Public health institution should develop
innovative ways of responding to the nursing shortage to ensure constant flow
of the nursing resources.

§Contracting
out Labor Intensive Nursing services

As a way
of immediate response to the problem of Nursing shortage the strategy of
contracting out labor intensive Nursing services to specialized organizations
can be employed. Such services may include care of bedsores, nutrition care for
patients and others. Though this has a potential of fragmenting patients care
may help a lot in providing quality care in times of crisis. This strategy does
not solve the problem of Nursing shortage as such but helps those setting hit
by the shortage to survive while providing quality care in the short run.In USA, Canada and Australia there are
increasing example of staff support services such as payroll, planning,
marketing and human resources being contracted out [5]. The net result has been
a decrease in staff costs, and access to more specialized expertise via
subcontracting with outside firms. In public health this has the potential of
increasing the time available for the few nurse to provide quality care to the
patients, and may provide the patients access to specialized nursing care for
some conditions from out side firms.

Salary and Remuneration

One of
the most important determinants of job or career choice is the salary or
remuneration that it provides. Nursing is consistently known to provide
remuneration inconsistent with education or work experience. The actual average
annual earnings of RNs employed full-time in 2000 were $46,782 [20]. However,
when changes in the purchasing power of the dollar were taken into account
utilizing the consumer price index, the “real” salaries of RNs employed full
time in 2000 was $23,369 (National Survey of RN nurse 2000). Real salaries for
nurses are actually very low compared to the amount and type of work they do.
This has left the nursing professional in limbo in terms of attracting new
students. Many nurses have left to seek for employment in better paying work
settings other than nursing or have gone back to school to change professions.
A reasonable revision of the remuneration for nurses based on qualification has
the potential of alleviating the situation. Remuneration is one the most
powerful motivating factor to any worker, and it increases job satisfaction,
and important in attracting new people to the profession.

REFERENCES.

1.
Elizabeth Temkin 2002, “Rooming-In: Redesigning Hospitals and Motherhood In
cold war America” Bulletin Of History in Medicine, 76: 271-298

2. James
Buchan 2002, “Nursing Shortage and evidence-based interventions: a Case study
from Scotland” International Council of Nurses, International Nursing Review,
49, 209-218.